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Infection Control Operational Policy/Version 10 /2014

Infection Prevention and Control Operational Policy

Author(s)

Vickie Longstaff (Infection Control Nurse Consultant)

Version

10 (Updated from January 2014 version)

Version Dat e December 2014

Implementation /approval Date

February 2015

Review Date

February 2016

Review Body Infection Control Committee

Policy Reference Number

48\tw\ic\icp\

Infection Control Operational Policy/Version 9/2014 2

Contents : 1.0 Introduction 3 2.0 Roles and responsibilities 3 3.0 Infection Control Committee Terms of Reference 4 4.0 The Infection Prevention and Control team 5 5.0 Key areas of infection prevention and control activities 7 6.0 Infection Prevention and Control Service Cover and Business Continuity 7 7.0 Education 9 8.0 Policy review 9 9.0 Monitoring/Audit 9 10. References / Bibliography 11 Appendix 1 Infection Prevention and Control Accountability and

Assurance Framework 12 Appendix 2 Infection prevention and control policy list 14 Appendix 3 Infection Prevention and Control Business continuity 15 Equality Impact Assessment 17 Policy Submission Form 19


1 Introduction The Trust’s Infection Prevention and Control Team (IPC team, IPCT) is a small team of staff with specialist knowledge within the field of infection prevention & control. The Team comprises the following staff:

Consultant Microbiologist and Director of Infection Control and Prevention (DIPC) (acting in their role as Infection Control Doctor)

2x Consultant Microbiologist (Laboratory Director and OPAT and orthopedic lead) Microbiology Specialist Registrar

Antibiotic pharmacist Nurse Consultant (ICNC)/Deputy DIPC. , 1 WTE

Band 7 infection control nurses (ICNs), 3 WTE for Homerton acute and community and 1 WTE for ELFT

Band 7 OPAT and Vascular access nurse Band 2 infection prevention & control team administrator, 0.7 WTE

This operational policy outlines the assurance framework with arrangements for infection prevention and control at the Homerton University NHS Foundation Trust. This operational policy was developed by the IPC team, and then distributed to all Members of the Infection Control Committee for endorsement and ratified by the Trust Policy Group. Scope This policy applies to all employees of the Trust in all locations including the Non-Executive Directors, temporary employees, locums and contracted staff. 2 Roles and Responsibilities The IPC team and service sits within the Children’s Services, Diagnostics, and Out-patients (CSDO). The Director of Infection Prevention and Control (DIPC) for the Trust is also the Infection Control Doctor and one of the Microbiology Consultants. They report to the Chief Executive Officer and Board whose responsibility it is to ensure that there are effective arrangements for Infection Prevention & Control within the Hospital. The DIPC deputises for the Consultant microbiologist laboratory Director in their absence. The Consultant microbiologist Laboratory Director or 3rd Microbiology Consultant deputises as infection control doctor in absence of the DIPC. The IPC team reports to the Infection Control Committee (ICC), which is a sub committee of the Trust Board (see below for ICC Terms of Reference). The Infection Control Nurse Consultant (ICNC) is also the Deputy DIPC, is responsible for the management of the infection prevention and control service and team and reports to the DIPC and Chief Nurse. The infection control nurses are responsible for ensuring that clinical, audit and education activities are in place and are accountable to and managed by the Infection Control Nurse Consultant. The Infection control and prevention accountability framework is available in Appendix 1.


3 Infection Control Committee Terms of Reference Authority The Infection Control Committee has been established to evaluate and report on all aspects of infection prevention and control and compliance with the Health and Social Care Act on behalf of the Board of Directors. The committee is a subcommittee of the Trust Board and reports directly to the Board. Purpose The purpose of the committee is to ensure that there is a managed environment within the Trust that minimises the risk of infection to patients, staff and visitors. The committee provides the Board of Directors with assurance that it has control of the HCAI agenda through compliance with HCAI regulatory requirements. Duties To ensure strategic and operational infection prevention and control risks are identified, assessed, evaluated and managed according to the risk management and assurance frameworks. To provide strategic direction and guidance to facilitate the development and implementation of infection prevention initiatives Trust wide. To promote a culture in which infection prevention and control will continue as an integral and seamless component of the healthcare process. To receive and approve the Infection Prevention and Control annual programme and audit programme ensuring the programme has clearly defined objectives. To monitor progress against Infection Prevention and Control performance key performance indicators using the balanced score card. To consider and respond to reports on:

Incidence and prevalence of alert organisms and important infectious disease Serious untoward incidents Infection prevention and control education and training Infection prevention and control practice and hospital hygiene Outbreaks of infection Audit

To ensure structures and processes are in place that enable hygiene code self- assessment and compliance. To define priorities based on current risk ratings detailed in the Infection Prevention and Control risk register. To review and endorse Trust policies for infection prevention and control, procedures and guidance and monitor their implementation through an annual programme of audit. To receive reports and monitor progress from the Infection Prevention Monitoring group To review and monitor outbreak management plans and monitor their implementation. To review other infection control issues as necessary, including those relating to catering, decontamination, engineering, ventilation and water services, employee health, pharmacy, procurement, capital strategy etc. To promote and facilitate education of all grades and disciplines of staff in procedures for the prevention and control of infection. To monitor the performance of the infection control team and make suggestions for improvement. To review the performance of the committee.


Membership Director of infection prevention and control (DIPC) - CHAIR Chief Nurse/Executive Director for infection control – DEPUTY CHAIR Members Medical Director Clinical Risk Manager Consultant Microbiologist Employee Health Lead Infection Control nurse consultant/Deputy DIPC Senior Nurse Children’s services, diagnostics & outpatients Senior Nurse Integrated medical & rehabilitation services

Senior nurse Surgery, Women’s and sexual health services

Head of Midwifery

Infection control nurses Director of Environment (Trust Decontamination Lead) Trust decontamination manager Facilities manager Estates water/ventilation lead Health Protection Team representative (nurse or CCDC) Non-Executive Director

Secretary The Infection Control Nurse Consultant shall act as secretary of the Committee. Quorum The quorum necessary for the transaction of business shall be six members, one of which must be the DIPC or Deputy Chair. Frequency of meetings and reporting Meetings shall be held quarterly The committee and DIPC will report to the board quarterly. It will be the responsibility of the relevant division leads to:

Devise and implement appropriate action plans Report progress to the Committee.

Review The Terms of Reference of this committee shall be reviewed annually.

4 Infection Prevention and Control Team

The Infection Prevention and Control (IPC) Team meets monthly. The IPC team (as above) and a Health Protection Unit representative attend. The regular agenda items for meetings are:

Clinical items: MRSA C. difficile MSSA bacteraemias E.coli bacteraemias GRE Pseudomonas in NICU/SCBU


Pseudomonas in ITU Invasive and Maternity cases of GAS Incidents and outbreaks Policy review programme Antimicrobial prescribing Audit programme Education programme PHE update Division updates ELFT update AOB

Issues discussed at the IPC team meetings may be included on the Infection Control Committee agenda as necessary. The DIPC provides a report to the Board quarterly. The Nurse Consultant/Infection control nurse attends the Trust Health and Safety and Patient Safety Committee meetings The IPC team provides specialist advice, formulates, monitors and evaluates the implementation of policies. The use of evidence-based practice is supported and used in the writing and reviewing of policies. The IPC team are responsible for the daily management and advice on infection control clinical cases and incidents. They also advise the Trust at a strategic level on service and building developments which will impact control and prevention. The IPC team develop and provide education to all Trust staff on infection prevention and control. The IPC team develop and complete a programme of audit relating to infection prevention and control. An Annual Report is produced by the DIPC and Deputy DIPC and presented to the ICC and Trust board. An Infection Prevention and Control Team Annual Plan is produced by the ICNC and DIPC and presented to the ICC for agreement. All members of the IPC team are registered for and fulfil Continuing Professional Development requirements. The IPC team will identify requirements for additional resources to support and promote infection control practices and present these to the ICC. The IPC team will fulfil the requirements of any SLA for a service with outside organisations. Currently SLAs are held with the St Josephs and Mildmay Hospital. The Trust provides a full Infection control service for mental health and community services to ELFT. The IPC team report to the Infection Control Committee. 5 Key Areas of Infection Prevention and Control Act ivity Clinical Activity Daily - The ICNs are informed of alert organisms from the microbiology laboratory daily. These are checked for new or existing cases. On identification of new cases the ICNs collect the demographic data on the patient and complete the MRSA, C.difficile and other alert organism surveillance spread sheets with the details. Data is entered onto the PHE Enhanced Surveillance Website as required. The ward is visited or community clinical team contacted and care pathways, patient information, advice on isolation/infection control precautions and appropriate treatment provided.


Three times weekly – The ICNs visit every inpatient area three times a week to review any patients known to the service, provide advice or information to staff on any existing patients not known to the service. This list is provided to the clinical site team on a 3 x weekly basis to assist in bed management and patient placement. This process allows for early identification of reduced capacity in side rooms for isolation. If there is a possibility of an inability to isolate this will be highlighted, risk assessments completed and contingency plans devised. Weekly – The IPC team carry out a C.difficile ward round and visit all wards with symptomatic cases of C.difficile and patients who are carriers of toxigenic strains of C.difficile (C.difficile toxin gene PCR positive) to review current and future case management. As required – Telephone advice or visits to wards/clinical areas to deal with any clinical queries. This also includes the control of outbreaks which involves the appropriate isolation of cases, support for staff, contact tracing, investigation of sources/reasons for outbreaks and planning of appropriate actions. Policy/Guideline Development The infection prevention and control policies (appendix 3) are available on the Trust intranet and undergo regular review. The policies are evaluated and updated following risk assessment and as new guidelines or evidence become available or, alternatively as a matter of Trust policy, every 3 years. There is a planned programme for the review of infection control policies and this process is reported to the ICC. The IPC team is also involved in advising departments on infection prevention & control aspects of their individual policies.

Audit Activities There is an annual audit programme of Infection Control/Environmental audits for clinical areas using a revised version of the IPS audit tool in conjunction with the Domestic services, ward sisters and Hotel Services Manager. The audit programme details dates for audits and a follow up meeting is arranged 4-6 weeks later to check on action points. There is an audit of compliance with key policies/practice areas. The planned audit programme is part of the Infection Prevention and Control annual plan. An audit report and action plan is prepared by the ICNs and distributed to the Clinical Divisions for action at Directorate level. High Impact Intervention monitoring is performed by clinical areas as part of the IPC annual programme. The monitoring takes place monthly using an Infection Prevention and Control Audit System (IPAS) and all results are sent to clinical managers, matron, clinical directors and executive directors. All audit activity is reported to the ICC and board as part of the Infection Prevention and Control Balanced Score Card. Surveillance Activities There is a Trust ‘Surveillance and Incident Reporting of Health Care Associated Infections’ Policy which contains more detailed information on the surveillance activities of the Trust. The surveillance activity is carried out using various methods such as laboratory system searches, and manual collation of data. This data is then used by the directorates for their performance reports and is a key performance indicator on the Trust Infection Prevention and Control Balanced Score Card.


Incident reporting and investigation There is a Trust ‘Surveillance and Incident Reporting of Health Care Associated Infections’ Policy which contains more detailed information on the process for incident reporting in the Trust. All HUH attributable MRSA bacteraemia and C.difficile cases are reported as part of the Trust Serious Incident (SI) procedure (regardless of outcome). All non HUH attributable MRSA bacteraemia and C.difficile cases are reported are reported as an incident with a Root Cause Analyses performed. All C.difficile and MRSA-related deaths (Part 1 of death certificate) are also reported as part of the SI process. All incidents requiring contact tracing are reported and investigated. All Serious Incidents and PIRs/RCA’s are reported to the Patient Safety Committee as per Incident reporting policy and ICC. Promotional Campaign Work The IPC Team aim to raise the awareness of staff across the Trust on infection prevention and control issues. This is done in various ways:

• Hand hygiene awareness weeks (at least annually) • Articles in the staff magazine (Homerton Life) • Continuous updating of the Infection Prevention & Control service page

on the Trust intranet. • Monthly/bi-monthly IPC newsletter • Promotion of various hand hygiene or new posters. • Presentations to various members of staff and public on infection control

issues. • Clean Your Hands campaign. • IPC team Twitter feed

Patient and Public Information The IPC team works with public and service users via the Patient Experience Group and various presentations at members meetings. The Trust website contains information on management of MRSA and C.difficile and a link to the PHE website for the Trust’s surveillance figures. There are information leaflets available on specific infections such as MRSA and C.difficile and infection prevention advice in the visitors information leaflet. 6 Infection Prevention and Control Service Cover an d Business Continuity The DIPC, the other Microbiology Consultant (Head of Department), the new 3rd Microbiology consultant and ICNC plan leave to ensure that one is available for service cover. The infection control nurse service leave is arranged to ensure that, where possible, there is no more than one of the three on annual leave at any one time. The OPAT/ VAN co-ordinates her leave with infection control nurses to ensure they are available to cover the service. A 24-hour infection control nurse service is not available. Out-of-hours, the Trust’s Microbiologists provide infection prevention and control cover for the Trust. Infection prevention and control advice is provided by the Microbiology SpR or Consultant on-call. If the Microbiology SpR is 1st on call, there is always a Microbiology consultant 2nd on call for further expert advice as required. Individual doctors may access this service for infection prevention and control queries on individual patients, otherwise this service is usually accessed through the Clinical Site Managers e.g. for out-of-hours outbreak


management advice. The infection prevention and control advice given is then handed back to the Homerton IPC team at the beginning of the next working day for further action. A Business Continuity Plan has been developed to ensure service provision if multiple staff members are on prolonged unavoidable leave (Appendix 5). This also covers the ability to continue to provide the SLA with other organisations. 7 Education Infection Prevention and Control training is part of the trust mandatory training programme contained in the Trust Mandatory training Policy available on the intranet/ Monitoring of training requirements, attendance and non-attendance is the responsibility of the line managers of staff. Attendance compliance is monitored by the Training Committee, Infection Control Committee and reported to the Trust Board via the mandatory training balance score card and infection prevention and control balance score card. Divisions are responsible for monitoring their staff attendance and addressing non-attendance. The Trust has a cohort of Infection Control Link Practitioners for all clinical areas. The link practitioner days are run quarterly with the specific training sessions and feedback of recent audit reports. 8 Review This policy will be reviewed annually. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance. 9 Monitoring/Audit All aspects of this operating policy will be monitored by the ICC via IPC team reports and evidenced by committee minutes. Key outcome indicators for service provision include the number of MRSA bacteraemia cases, C.difficile cases and SUIs, these are all reported to and monitored by the ICC and reported to the board in the DIPC quarterly reports. Measurable Policy Objective

Monitoring/Audit Frequency of monitoring

Responsibility for performing the monitoring

Monitoring reported to which groups/committees, inc responsibility for reviewing action plans

Clinical activities

Surveillance activity

Training data

Promotional work

Infection control reports to the ICC

Quarterly Infection control team

Quarterly reports to ICC and included in DIPC reports to the board.


10. References / Bibliography Department of Health, Winning Ways. Working together to reduce Healthcare Associated Infection in England. Report from the Chief Medical Officer. Dec 2003. Hospital infection society, Infection control nurses association, Association of medical microbiologists and Department of Health working group. Key Indicators. 2001. www.icna.co.uk/key%20indicators1.htm Department of Health. Getting ahead of the curve: a strategy for combating infectious diseases (including other aspects of health protection). A report by the Chief Medical Officer. London: Department of Health; 2002 Department of Health Standing Medical Advisory Committee Sub-group on Antimicrobial Resistance. The Path of Least Resistance: summary and recommendations. London: Department of Health; 1998. Department Of Health. Saving Lives. A Delivery programme for reducing health care associated infections including MRSA, 2005. Department of Health. The Health and Social care Act 2009. The Code of practice for the reduction in health care associated infection.


Appendix 1

INFECTION PREVENTION & CONTROL ACCOUNTABILITY AND ASSURANCE FRAMEWORK

Board of Directors

DIPC Consultant in Infection Control Infection Control Committee (DIPC Chair)

Infection Control Sub Committees • Decontamination monitoring

• I

Infection Control Team Consultant Infection Control (Deputy DIPC) Consultant Microbiologists Consultant Nurse Infection Prevention Control Infection Control Nurse x4 ICT administrator Pharmacist

Chief Executive Chief Nurse & Director of Governance

Clinical Teams Performance and Governance Committees


Regularity Information Tree Reporting Response to Variance

Quarterly Trust Board DIPC report – surveillance data, incidents and outbreaks, SUIs, audit programme, matron monitoring group, education programme, IPC BSC, risk register, cleaning standards, estates and facilities reports (Legionella, ventilation, decontamination) and employee health reports

Frequency of meetings may be increased or decreased in response to specific situations such as an outbreak. This would be reflected in IPC reports and DIPC reports to the Board.

Quarterly Infection Control Committee Surveillance data, incidents and outbreaks, SUIs, audit programme, education programme, IPC BSC, risk register, cleaning standards, estates and facilities reports (Legionella, ventilation, decontamination) and employee health reports

Quarterly Health and Safety Committee Needle stick injuries, latex allergy Quarterly Water Safety Group Monitors the water safety plan and arrangements. Quarterly Antimicrobial Management Group Antimicrobial stewardship issues e.g. new antimicrobials, antibiotic

prescribing incidents, antibiotic policy updates Monthly

Chief Executive and DIPC Director of Nursing and Infection Control Nurse Consultant

Key issues Instant reporting of HCAI issues

Monthly Domestic and Catering Services Review Group

Performance against National Standards of Cleanliness

Monthly Patient Safety Committee RCAs, SIs Monthly Joint Prescribing Group Antimicrobial prescribing Quarterly Decontamination Monitoring Group Decontamination of equipment, SSD audits and compliance,

endoscopy audits and compliance Monthly Infection Control Team meetings Surveillance data, SUIs, policy review programme, audit

programme, antimicrobial prescribing, education Weekly DIPC and ICN meetings Key issues

Instant reporting of HCAI issues Monthly Daily Ad hoc

Wards HII, audit, C.difficile, MRSA and cleaning


Appendix 2 – Infection Prevention and Control Polic y List

Current policy status Planned review date

Aseptic (ANNTT) technique policy Jan-14 Jan-17

Blood Culture policy Apr-14 Mar-17

CJD/TSE 2010 Nov-16

Clostridium difficile 2012 Mar-15

Control of MRSA 2013 Sep-16

Control of viral haemorrhagic fevers Apr-14 Mar-17

Death of an infectious patient 2010 Nov-16

Decontamination of re-usable medical Equipment 2011 Dec-14

Endoscope decontamination 2012 Mar-15 Environment and isolation room cleaning and disinfection of body fluid spillages Jan 2014 Jan-17

Food Hygiene 2012 Sep-15 GRE May-14 May-17

Hand hygiene 2011 Nov-16

Infection Control Operating policy Jan 2014 Jan-17

Inoculation/NSI injury 2013 2016

Invasive Group A Step 2012 Nov-15

Isolation policy 2010 Nov-16

IV Line associated infections Apr-14 May-17

Laundry disposal 2013 Sep-16

Major outbreak policy Jan 2014 Jan-17

Meningococcal meningitis Apr-14 May-17

Multi-resistant gram negative policy 2014 Feb-17

Norovrius Diarrhoea and Vomiting policy 2013 May-16

Notification of infectious diseases 2013 Sep-16

Pandemic Flu plan Aug-14 Aug-15

Pest control 2011 Dec 2014 Protection against BBV and NSI 2013 Apr-16

Rabies Policy Feb-13 Feb-16

Single use medical devices 2013 Sep-16

Standard Infection Control Precautions Apr-14 May-17

Surgical Site Infection Policy Jan 2014 Jan-17

Surveillance policy and reporting HACI 2013 Sep-16

TB 2013 May-16

Tunnelled CVC/ Hickman line Apr-14 May-17 Varicella zoster virus 2012 Nov-15

PICC policy Jan-14 Jan-17


Appendix 3 Infection Control Business Continuity Pl an (please also refer to the Trust Business Continuity plan) The Trust IPC team is a small team of staff with specialist knowledge within the field of infection prevention and control. The team comprises of:

Consultant Microbiologist and Director of Infection prevention and control (DIPC)

(acting in their role as Infection Control Doctor)

Consultant Microbiologist laboratory Director

Microbiology Specialist Registrar

Antibiotic pharmacist

Nurse Consultant (ICNC). 1 WTE

Band 7 infection control nurse (ICN). 4 WTE

Band 7 OPAT/Vascular access nurse. 1 WTE

Band 2 infection control team administrator. 0.7 WTE

The IPC Business Continuity Plan would be required if there were severe reduced staff levels and/or long term reduced levels of staff within the Infection Prevention & Control Team or as part of the Trust Business Continuity. The team’s leave is planned to ensure that there is always clinical staff available at an appropriate level. The Director of Infection Prevention and Control, Consultant Microbiologist laboratory Director, the new 3rd Microbiology consultant and Nurse Consultant plan leave so that there is little or no over lap to ensure that there is advice available at a senior level. The other team members leave is planned so that there are usually at least 2 infection control nurses available to reduce risk of the service being left uncovered. The infection control nurses cover the vascular access/OPAT service when the nurse is on leave or sick. The BCP would need to be considered if the DIPC and nurse consultant were not available for a prolonged period of time (over 3 weeks). It would also need to be considered if there were to be reduced levels of staffing for prolonged periods of time, for example if there was no admin support available due to long term sickness or leave or if one or two of the band 7 infection control nurses/ OPAT and VAN were on unplanned prolonged leave. For the purpose of considering this BCP unplanned prolonged periods of leave should include leave of over 4 weeks depending on number of staff involved. Management Action The IPC Team’s Operational Procedure and Surveillance and Incident Reporting Policy contains information on specific actions in relation to mandatory surveillance procedures. Team members regularly cover each other’s leave and therefore any specific procedures relating to mandatory requirements should be known to another team member. The impact of any changes in service provision would need to be discussed with the Chief Nurse and the Chief Executive made aware if there are possible risks relating to compliance with statutory requirements (e.g. Health and Social Care Act 2009). The ability to continue to provide the SLA to Mildmay and St. Joseph’s would need to be considered and contingency plans put in place. The full service provided to East London Foundation Trust would need to be covered by other means (e.g. locum cover for SLA). Escalation to Major Incident In the event of a major incident relating to IPC team, such as a major outbreak and a sudden reduced staffing capacity, the Health ProtectionTeam (PHE), London Borough of Hackney be contacted. If the major outbreak was part of a flu pandemic then some of the pro-active work may need to cease and the IPC Team staffing resources would be


acting as part of the pandemic flu plan and be advising the Trust and staff on reducing risk and managing cases.


Action By Whom Expected Outcome

In the absence of the DIPC the consultant microbiologist laboratory Director or 3rd Microbiology consultant will deputise as infection control doctor

Consultant microbiologists

There would continue to be infection control doctor cover.

In the absence of the DIPC or nurse consultant the other would take over the team position in relation to continuing to comply with all mandatory surveillance reporting. Where necessary any actions will be taken over or allocated to other team members. All processes are contained within the team operational procedure or surveillance and incident reporting policy.

DIPC or nurse consultant

The service would continue with a probable reduction in the pro-active strategic work.

In the absence of the nurse consultant the ICNs with the DIPC would review and rationalise the groups, meetings and diary commitments of the nurse consultant.

DIPC and band 7 ICN

The ICT would run a day to day clinical service with reduced capacity for proactive work. The re-active clinical activity of the service would continue. The strategic developmental work under taken by the nurse consultant would need to be on hold.

In the absence of the DIPC and nurse consultant the consultant microbiologists would be expected to become more involved in the activities of the ICT to support the junior team members.

Consultant Microbiologists

The ICT would run a day to day clinical service with reduced capacity for proactive work. The re-active clinical activity of the service would continue. The strategic developmental work would be on hold.

In the absence of one of the ICN’s or vascular access/OPAT nurse the infection control pro-active programme would need to be reviewed. This would involve a reduction in the amount of education and audit work performed.

Nurse Consultant The reactive clinical service would continue. The pro-active audit and education programme would be run at a reduced level due to reduced team capacity.

In the absence of 2 of the infection control nurses or vascular access/OPAT nurse the infection control pro-active programme would need to be reviewed. This would involve a reduction in the amount of education and audit work performed. Arrangements for locum cover would need to be considered.

Nurse Consultant/ DIPC

The reactive clinical service would continue. The pro-active audit and education programme would need to be suspended depending on locum cover provision.

Resumption of Normal Business Activity/Debriefing a nd Analysis Normal services would resume when the IPC team is up to the recommended team establishment in the beginning of the BCP. On resuming normal business the effectiveness of the BCP will be reviewed and any alterations made.


Equalities Impact Assessment This checklist should be completed for all new Corporate Policies and procedures to understand their potential impact on equalities and assure equality in service delivery and employment. Policy/Service Name: Infection Control Operational Policy

Author: Vickie Longstaff Role: Nurse consultant Directorate: Childrens services, diagnostics & outpatients Date December 2014

Equalities Impact Assessment Question Yes No Comment

1. How does the attached policy/service fit into the trusts overall aims?

Yes Compliance with health and social care act 2009

2. How will the policy/service be implemented?

Systems already in place as any changes have already been implemented

3. What outcomes are intended by implementing the policy/delivering the service?

Compliance with health and social care act 2009

4. How will the above outcomes be measured?

Compliance with health and social care act 2009

5. Who are the key stakeholders in respect of this policy/service and how have they been involved?

Infection control committee given opportunity to comment

6. Does this policy/service impact on other policies or services and is that impact understood?

No

7. Does this policy/service impact on other agencies and is that impact understood?

No

8. Is there any data on the policy or service that will help inform the EqIA?

No

9. Are there are information gaps, and how will they be addressed/what additional information is required?

No


Equalities Impact Assessment Question Yes No Comment

10. Does the policy or service development have an adverse impact on any particular group?

No

11. Could the way the policy is carried out have an adverse impact on equality of opportunity or good relations between different groups?

No

12. Where an adverse impact has been identified can changes be made to minimise it?

N/A

13. Is the policy directly or indirectly discriminatory, and can the latter be justified?

No

14. Is the policy intended to increase equality of opportunity by permitting Positive Action or Reasonable Adjustment? If so is this lawful?

N/A

EQUALITIES IMPACT ASSESSMENT FOR POLICIES AND PROCEDURES

2. If any of the questions are answered ‘yes’, then the proposed policy is likely to be

relevant to the Trust’s responsibilities under the equalities duties. Please provide the ratifying committee with information on why ‘yes’ answers were given and whether or not this is justifiable for clinical reasons. The author should consult with the Director of HR & Environment to develop a more detailed assessment of the Policy’s impact and, where appropriate, design monitoring and reporting systems if there is any uncertainty.

3. A copy of the completed form should be submitted to the ratifying committee

when submitting the document for ratification. The Committee will inform you if they perceive the Impact to be sufficient that a more detailed assessment is required. In this instance, the result of this impact assessment and any further work should be summarised in the body of the Policy and support will be given to ensure that the policy promotes equality.


Policy Submission Form

To be completed and attached to any policy or procedure submitted to the Trust Policy Group 1 Details of policy 1.1 Title of Policy: Infection Prevention and Control Operational

Policy 1.2 Lead Executive Director Chief Nurse and Director of Governance

1.3 Author/Title Vickie Longstaff (Nurse Consultant)

1.4 Lead Sub Committee Infection control committee

1.5 Reason for Policy Compliance with health and Social Care Act 2009

1.6 Who does policy affect? All Trust staff

1.7 Are national guidelines/codes of practice incorporated?

Yes

1.8 Has an Equality Impact Assessment been carried out?

Yes

2 Information Collation 2.1 Where was Policy information

obtained from? Health and Social care act 2009

3 Policy Management 3.1 Is there a requirement for a new or

revised management structure if the policy is implemented?

No

3.2 If YES attach a copy to this form N/A

3.3 If NO explain why Systems already in place

4 Consultation Process 4.1 Was there internal/external

consultation? Internal – Infection control committee

4.2 List groups/Persons involved Infection control committee – January 2015 group

4.3 Have internal/external comments been duly considered?

Yes

4.4 Date approved by relevant Sub-committee

January 2015

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